Friday, October 2, 2009

The Boston Globe: Let's Ban Hired Guns

Yesterday, the Boston Globe published an excellent editorial entitled: “Keep doctors independent; ban fees from drug makers.” Responding to revelations that Eli Lilly paid out $22 million in fees for promotional talks to doctors over the first 3 months of 2009, the Globe believes that “legislators should go beyond requiring disclosure of the relationships, and ban the practice.”

The piece soundly concludes that:

"Patients trust doctors as stewards of their health. They revere them as scientists who can exercise sound, independent judgment. Allowing doctors to promote drugs for pharmaceutical companies takes advantage of that trust and reverence. It also compromises doctors’ most important work: treating people who are ill."

I agree that doctors should cease speaking for drug companies, though I’m not convinced that legislation is the best way to accomplish this. Since the practice is unethical, it should be regulated in the same way that other matters of medical ethics are regulated—via medical societies and state medical licensing boards.

At any rate, I perused some of the dozens of comments to the Globe's editorial, and here are three common categories, along with my rebuttals.

1. Doctors are not wealthy and greedy. They train hard, only make around $150,000 per year, have lots of overhead, etc. Doctors are so poor that they need and deserve to supplement their income by speaking for drug companies.

Here’s a news flash, people. Most doctors are not poor; in fact, they are rich. In 2008, the average physician income ranged from a “low” of $159,000 (family practitioners) to a high of $527,000 (neurosurgeons). This places their income in the top 5-10% of all American wage earners, according the health economist Uwe Reinhardt.

Doctors don’t speak for drug companies because they need the money to feed and clothe their starving families. They do it because it’s fun and interesting, provides narcissistic satisfaction, a social outlet, and gives them extra money for the finer things in life. The point of the editorial is that doctors should make their money by practicing medicine rather than by promoting drugs.

2. But how will doctors get their medical education if drug companies can’t pay experts to give lectures?

There are hundreds of medical journals covering every conceivable specialty—here’s one list of them. Likewise, here is a directory of the hundreds of medical conferences throughout the US held in every state, varying widely in cost. Most medical education lectures are held in hospitals and academic medical centers as part of grand rounds, most of which are freely available to doctors in the community. The funding varies, sometimes coming from medical staff fees, sometimes from drug company money donated to a pool of funds that can be used at the hospital’s discretion—a far cry from doctors signing contracts to speak for drug companies.

3. You think doctors are greedy? What about congressmen and senators—look at all the money they get from drug companies and insurance companies. That’s where you should focus.

First, all contributions to elected officials are transparent and are available from a number of websites, such as http://www.opensecrets.org/. Second, politicians have, by definition, innumerable different consituents and interests, and it is appropriate that they receive campaign donations from these varied constituents. Not so for doctors. We don’t have different “constituents.” We have a single constituent: our patients. Our single professional responsibility is to treat them. On the other hand, we have no responsibility to drug companies to help them sell their drugs, and therefore we have no responsibility to accept money from them for that purpose. Research is different, because medical research is directly related to patient care, and so accepting drug company money for clinical research is far more defensible.

Kudos to the Boston Globe for taking such a strong and principled position on this issue.

9 comments:

Anonymous
said...

One nit-picky point: Your source for Physician's salaries is generated from a Merritt & Hawkins (a large headhunting firm) review of recruiting incentives.

I'd agree with the main point that doctors aren't poor - but, by the time that a company is ready to hire a headhunter (a decision that will cost the hiring agency over $100k), they're pretty desperate - and realize that they have to make very attractive offers.

Also, considering that their methodology isn't published, and they stand to profit from higher estimates of physician salaries, I'd believe that the results of this "survey" might be somewhat higher than might be found with other (and, perhaps, better?) methodologies.

I agree that ethics should be regulated by medical societies and medical boards. But these days, most medical societies get substantial amounts of money from pharma/ biotech/ device etc. As long as that continues, they are no longer in a position to police physiicans' ties to the same companies.

Furthermore, as noted here:http://hcrenewal.blogspot.com/2009/06/why-did-us-physicians-give-up-their.htmla 1970s US Supreme Court decision about US anti-trust law has been interpreted to mean that physicians' societies cannot regulate the ethics of their members. (At one time, the AMA forbade the commercialization of medicine.)

So maybe that law would also have to be changed before it would be realistic to even think about having medical societies police these ethical issues.

Regarding physician continuing education and awareness, I simply cannot understand how information technology is not being fully exploited to solve that problem.

Every lecture and seminar everywhere can be recorded and made accessible via the web. All it takes is the desire of your professional organizations to coordinate an archiving process and make it happen. I'm sure they could build in a cost recovery model without much problem.

The systemic problem though is probably analogous to the NCAA and the NFL/NBA de facto partnerships. The pathological symbiotic relationships are just too strong and to ingrained to rupture.

So you tilt at windmills or you go along to get along. Must be psychically exhausting. Tough choice for the M.D.'s who care enough to get exercised.

Why does it take editorials in newspapers to state the obvious? Look: When I go into a car dealership, I know before hand that the sales rep’s only job and purpose is to hose me and sell me on a car. He or she will spin the car any way possible to make the sale. Period. We all know that going into a dealership and are therefore (hopefully) prepared and vigilant. I don’t want to have to be “prepared” to go see my doctor. I suppose another solution to this problem would be to require doctors to wear Pharma company labels or stickers on their jackets or foreheads. You know, you can go see Dr. X and he/she greets you with an “I am shilling Zyprexa/Cymbalta for Lilly” badge. I guess that would be fair. Or at least a step forward.

I'm not sure that getting one's continuing education and "new" information from medical journals is a vast improvement over CME given all the ghost writing and heavy control through advertising that the pharmaceutical companies currently enjoy to say nothing of how they manipulate the clinical trials that are being written up in the first place. From my perspective I actually think it looks pretty hard for doctors to get decent continuing education. If patients' experiences were tracked and monitored more closely than they are now and doctors really listened that would be one good way to get a lot better "education."

I am proud to say that my doctor's office has ceased allowing drug companies to provide them with samples or other advertising goodies like pens and paper pads, etc. My doctor said it was a decision they made because they felt it wasn't right to promote drugs that way, and they wanted to cater to the patients, not the pharmaceutical companies. I gave her two thumbs up for that one.

Excellent points but looking from afar at the US health sytem that costs 40% to 110% more than the other 19 OECD countries to run and can't provide universal health cover and less redtape in the way of doctors - like the other 19 OECD countries....I agree with SteveM...politicians are beholden in the USA (more than most other developed nations) to not just lobbyists but the richest lobbyists - and who are those? Big Pharma and the Managed Care for profit insurers who rake in much if not more than that extra 40% to 110% that other countries don't pay.

see http://www.guardian.co.uk/world/2009/oct/01/lobbyists-millions-obama-healthcare-reform

The influence of big Pharma is far less costly that the perverse incentive of fee for service. Your doctor may prescribe one antidepressant over another because she was paid by the pharmaceutical company (an unlike scenario IMO), or because she went to dinner (paid for by pharma) and heard the shill spin a convincing tale in favor an expensive patented drug over an equally effective generic drug (a more likely scenario). However, that's nothing compared to having your uterus removed unnecessarily, or the extra CT scans, biopsies, and so forth because your doctor gets paid to perform these operations and tests. Single payer off the table? How many politicians have undisclosed money deposited in central American banks by insurance companies. Clean up this mess first!